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166 Cards in this Set
- Front
- Back
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What is the effect of insulin's presence on muscle?
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Protein Synthesis
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What is the effect of insulin's absence on muscle?
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Gluconeogenesis
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What is the effect of insulin's presence on the liver?
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Glycogenesis
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What is the effect of insulin's absence on the liver?
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Glycogenolysis
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What is the effect of insulin's presence on adipose tissue?
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Lipogenesis
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What is the effect of insulin's absence on adipose tissue?
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Lipolysis
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Peptide hormone, secreted by the alpha cells in the pancreas, that raises blood glucose levels.
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Glucagon
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Group of gastrointestinal hormones that cause an increase in the amount of insulin released from the beta cells of the islets of Langerhans after eating, even before blood glucose levels become elevated.
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Incretins
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Incidence: Type 1 vs Type 2 DM
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10% Type 1, 90% Type 2
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Age of Onset: Type 1 vs Type 2 DM
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Childhood/Puberty for Type 1, Usually over 40 yo for Type 2
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Presentation: Type 1 vs Type 2 DM
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Sudden for Type 1, Gradual for Type 2
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Family History: Type 1 vs Type 2 DM
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Uncommon for Type 1, Strong for Type 2
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Pathogenesis: Type 1 vs Type 2 DM
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Postulated environmental insult coupled w/ genetic susceptibility for Type 1, Eight defects associated w/ Type 2
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Plasma Insulin: Type 1 vs Type 2 DM
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Absent in Type 1; May be low, normal, or elevated in Type 2
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Exogenous Insulin: Type 1 vs Type 2 DM
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Required for Type 1, Necessary in greater than 20 to 30% of patients for Type 2
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How many units of insulin are typically produced by an adult per day?
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40 Units
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What are the ADA and AACE goals for A1c?
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ADA: <7%, AACE: <6.5%
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What are the ADA and AACE goals for preprandial plasma glucose?
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ADA: 70 to 130 mg/dL, AACE: < or = 110 mg/dL
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What are the ADA and AACE goals for peak postprandial plasma glucose?
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ADA: < 180 mg/dL, AACE: < or = 140 mg/dL
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What is the ADA goal for bedtime glucose?
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ADA: 100 to 140 mg/dL
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What are the ADA and AACE goals for blood pressure?
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Both are < 130/80 mmHg, although the ADA advises individualization as needed.
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What is the ADA goal for total cholesterol?
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< 200 mg/dL
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What are the ADA and AACE goals for LDL cholesterol?
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Both are < 100 mg/dL, although the ADA lists the option of < 70 mg/dL for overt CVD and an alternate goal of decreasing LDL 30 to 40% from baseline.
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What are the ADA and AACE goals for triglycerides?
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Both are < 150 mg/dL
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What are the ADA and AACE goals for HDL cholesterol?
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Both are > 40 mg/dL for men and > 50 mg/dL for women
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What are the ADA, JNC 7, and K/DOQI recommendations for the therapeutic goal of blood pressure in diabetic patients?
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Both the ADA and JNC 7 recommend < 130/80, while K/DOQI recommends < 125/75.
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What does the ADA recommend with respect to statin use in patients having DM?
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The ADA recommends statins + lifestyle modifications in all DM patients, regardless of baseline lipids.
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What does U100 and U500 denote? What does Pigarelli say about abbreviations with respect to insulin units?
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U100 is 100 units/mL, while U500 is 500 units/mL. Pigarelli says NEVER use an abbreviation for units. ALWAYS write out "units." This is a patient safety issue.
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Which two insulin products are available OTC?
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Regular and NPH insulin are both available OTC.
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For how long can an in-use vial of insulin be stored at room temperature?
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Up to 28 days
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Which insulin formulations are okay to mix in a syringe and which should never be mixed?
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Intermediate- and rapid-acting analogues are okay to mix in a syringe. Long-acting analogues should never be mixed.
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What is the correct manner in which to withdraw insulin doses from vials in order to mix a clear formulation, such as regular insulin or a rapid-acting analogue, with NPH, which is cloudy?
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Set the two vials down on the counter. Put air into the cloudy first and take the syringe straight back out. Then put air into the clear and then automatically tip the clear vial upside down and withdraw the clear dose. And then insert the syringe back into the cloudy vial and withdraw the cloudy dose.
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What is the maximum ratio of NPH to clear insulin that is okay to utilize?
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3:1 or 4:1 NPH to clear.
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For how long is a mixed insulin preparation good if stored in the refrigerator?
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3 wks
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For what three reasons is the abdomen the preferred site for subcutaneous insulin injections?
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1) The area of subcutaneous fat, the thickness, is most consistent across the abdomen. 2) The back of the arms, buttocks, and thigh have more variable blood flow, which can change absorption characteristics, 3) The likelihood of accidentally injecting into muscle is much less, with proper technique, in the abdomen.
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At what angle should a subcutaneous insulin injection be made?
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Insulin should be injected at a 90 degree angle unless it is being injected into a very skinny person or a child, in which case a 45 degree angle should be used.
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What are two injection site problems, aside from bruising, that can occur? What should be done about sites of bruising or nodules, and why?
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One is lipoatrophy, which is where the fat tissue atrophies, and another is lipohypertrophy, where that fat tissue hypertrophies and gets ugly. If a patient notices bruising or nodules, they should avoid injecting at that site because it can lead to these problems, which can completely alter insulin absorption.
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What are the three rapid-acting insulin types (brands)?
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Lispro (Humalog), Aspart (Novolog), and Glulisine (Apidra)
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What are the two brands of short-acting regular insulin?
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Humulin R and Novolin R
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What are the two intermediate-acting types (brands) of insulin?
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NPH (Humulin N & Novolin N) and Detemir (Levemir)
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What are the two long-acting insulin types (brands)?
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Glargine (Lantus) and Detemir (Levemir)
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What is the onset of action, peak, and duration of action for rapid-acting forms of insulin?
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Onset of Action: 5 to 15 min, Peak: 1 to 2 hrs, Duration of Action: 2 to 4 hrs
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What is the onset of action, peak, and duration of action for short-acting forms of insulin?
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Onset of Action: 30 to 60 min, Peak: 2 to 4 hrs, Duration of Action: 4 to 6 hrs
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What is the onset of action, peak, and duration of action for NPH (Humulin N or Novolin N)?
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Onset of Action: 1 to 2 hrs, Peak: 4 to 8 hrs, Duration of Action: 10 to 20 hrs
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What is the onset of action, peak, and duration of action for detemir (Levemir)?
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Onset of Action: 1 to 2 hrs, Peak: 6 to 8 hrs, Duration of Action: Dose-Dependent [6 to 12 hrs for a dose of < 0.4 units/kg and 20 to 24 hrs for a dose of > 0.4 units/kg]
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What is the onset of action, peak, and duration of action for glargine?
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Onset of Action: 1 to 2 hrs, Peak: Flat, Duration of Action: ~24 hrs
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What is the insulin type (brands) having a cloudy appearance?
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NPH (Humulin N & Novolin N)
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What is the appropriate meal timing for lispro (Humalog)?
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15 min before or immediately after
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What is the appropriate meal timing for aspart (Novolog)?
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5 to 10 min before
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What is the appropriate meal timing for glulisine (Apidra)?
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Within 15 min before or within 20 min after starting a meal
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What is the appropriate meal timing for NPH (Humulin N or Novolin N)?
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Within 15 min before meals when mixed with rapid-acting insulin; 30 min before when mixed with regular insulin
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What are the 5 Treatment Goals with Type 1 Diabetes?
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1) Euglycemia, 2) Prevent hypo- or hyperglycemia, 3) Normal growth & development, 4) Eliminate cardiovascular risks, & 5) Patient self-management
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What is the appropriate insulin dosing for the initiation of treatment for T1DM?
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Initial Treatment: 0.5 to 0.8 units/kg/day, 50% as basal, 50% divided for meal (prandial) boluses (might be 30% basal, 70% prandial).
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What is the appropriate dosing for the "honeymoon phase" of T1DM?
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0.2 to 0.5 units/kg/day or less
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What is the appropriate dosing in cases of DKA, acute illness, or adolescents for T1DM?
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1.0 to 1.5 units/kg/day
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Describe Conventional, i.e. "Split-Mixed Dose" Therapy for T1DM.
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2 injections per day with 2/3 daily dose in AM and 1/3 daily dose in PM. Each dose is 2/3 NPH + 1/3 Regular Insulin, although a 1/2 & 1/2 mix is becoming more common for PM dosing.
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Describe the "More Intensive Regimin" for T1DM.
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Conventional AM dose, split PM dose, i.e. 3 injections per day, with 2/3 daily dose in AM, 1/3 daily dose in PM. AM dose: 2/3 NPH + 1/3 Regular. PM dose: 1/3 Regular (or 1/2) given with evening meal and 2/3 NPH (or 1/2) given at bedtime.
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Describe the "Most Intensive Regimen" for T1DM.
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4+ injections per day. 50% total daily dose as regular, lispro, aspart, or glulisine, divided among meals (1/6 daily dose w/ breakfast, 1/6 w/ lunch, 1/6 w/ dinner). 50% (3/6) total daily dose, as glargine or detemir, at bedtime.
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By how much does 1 unit of insulin generally lower blood glucose?
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30 to 50 mg/dL
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What is the recommended carb intake at meals for women and men?
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45 to 60 g per meal for women, 60 to 75 g per meal for men
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What are the 8 Treatment Goals with Type 2 Diabetes?
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1) Euglycemia, 2) Prevent morbidity/mortality from macrovascular complications, 3) Tight control in most patients, 4) Improved QOL, 5) Prevent hypoglycemia, 6) Blood pressure control, 7) Lipid management, & 8) Prevention of long-term complications
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In what drug class is glipizide and what is the mechanism of action for drugs in its class?
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Glipizide is a sulfonylurea. Sulfonylureas stimulate insulin secretion, which reduces fasting plasma glucose.
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In what drug class is glimepiride and what is the mechanism of action for drugs in its class?
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Glimepiride is a sulfonylurea. Sulfonylureas stimulate insulin secretion, which reduces fasting plasma glucose.
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In what drug class is glyburide and what is the mechanism of action for drugs in this class?
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Glyburide is a sulfonylurea. Sulfonylureas stimulate insulin secretion, which reduces fasting plasma glucose.
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In what drug class is metformin and what is the mechanism of action for drugs in this class?
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Metformin is a biguanide. Biguanides target hepatic cells, decreasing hepatic glucose production to reduce fasting plasma glucose. It does not stimulate insulin secretion.
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In what drug class is pioglitazone (Brand?) and what is the mechanism of action for drugs in this class?
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Pioglitazone (Actose) is a thiazolidinedione. Thiazolidinedions regulate insulin response genes necessary for the metabolism of glucose and lipids, leading to improved insulin sensitivity in muscle and adipose tissue.
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In what drug class is repaglinide (Brand?) and what is the mechanism of action for drugs in this class?
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Repaglinide (Prandin) is a meglitinide. Meglitinides augment glucose-induced insulin output.
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In what drug class is nateglinide (Brand?) and what is the mechanism of action for drugs in this class?
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Nateglinide (Starlix) is a meglitinide. Meglitinides augment glucose-induced insulin output.
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In what drug class is acarbose (Brand?) and what is the mechanism of action for drugs in this class?
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Acarbose (Precose) is an alpha-glucosidase inhibitor. Alpha-glucosidase inhibitors slow the absorption of carbohydrates, reducing post-prandial blood glucose.
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In what drug class is miglitol (Brand?) and what is the mechanism of action for drugs in this class?
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Miglitol (Glyset) is an alpha-glucosidase inhibitor. Alpha glucosidase inhibitors slow the absorption of carbohydrates, reducing post-prandial blood glucose.
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In what drug class is sitagliptin (Brand?) and what is the mechanism of action for drugs in this class?
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Sitagliptin (Januvia) is a dipeptidyl peptidase 4 inhibitor (DPP-4 inhibitor). Incretins (GLP-1 and GIP), which are inactivated by DPP-4, inhibit glucagon release, increase insulin secretion, and slow the rate of gastric emptying to reduce blood glucose levels.
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In what drug class is saxagliptin (Brand?) and what is the mechanism of action for drugs in this class?
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Saxagliptin (Onglyza) is a dipeptidyl peptidase 4 inhibitor (DPP-4 inhibitor). Incretins (GLP-1 and GIP), which are inactivated by DPP-4, inhibit glucagon release, increase insulin secretion, and slow the rate of gastric emptying to reduce blood glucose levels.
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In what drug class is linagliptin (Brand?) and what is the mechanism of action for drugs in this class?
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Linagliptin (Tradjenta) is a dipeptidyl peptidase 4 inhibitor (DPP-4 inhibitor). Incretins (GLP-1 and GIP), which are inactivated by DPP-4, inhibit glucagon release, increase insulin secretion, and slow the rate of gastric emptying to reduce blood glucose levels.
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What ADRs are associated with glipizide?
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Hypoglycemia, Weight Gain
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What ADRs are associated with glimepiride?
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Hypoglycemia, Weight Gain
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What ADRs are associated with glyburide?
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Hypoglycemia, Weight Gain
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What ADRs are associated with metformin?
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Diarrhea, Nausea, Abdominal Bloating, Anorexia
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What ADRs are associated with pioglitazone?
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Weight Gain, Edema, HF Symptoms, Macular Edema, Increased Fracture Rate, Increased Risk of Bladder Cancer
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What ADRs are associated with repaglinide?
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Hypoglycemia, Weight Gain
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What ADRs are associated with nateglinide?
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Hypoglycemia, Weight Gain
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What ADRs are associated with acarbose?
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Flatulence, Diarrhea, Abdominal Pain (less severe if titrated slowly)
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What ADRs are associated with miglitol?
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Flatulence, Diarrhea, Abdominal Pain (less severe if titrated slowly)
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What ADRs are associated with sitagliptin?
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Headache, Nasopharyngitis, Upper Respiratory Tract Infection [Severe Allergic Rxns are rare]
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What ADRs are associated with saxagliptin?
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Headache, Nasopharyngitis, Upper Respiratory Tract Infections [Severe Allergic Rxns are rare]
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What ADRs are associated with linagliptin?
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Nasopharyngitis [5.8% vs. 5.5% with placebo, therefore not statistically significant]
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How does the onset of action and duration of action of meglitinides compare with that of sulfonylureas?
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They have a more rapid onset of effect and a shorter duration of action than sulfonylureas.
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By what magnitude do thiazolidinediones decrease A1c?
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1.0 to 1.5%
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What effect does pioglitazone have on CV outcomes?
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Pioglitazone improves CV outcomes, in spite of concerns regarding worsening of HF symptoms.
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Which class of anti-diabetic medications may cause ovulation to resume in anovulatory women?
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Thiazolidinediones
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What classes of anti-diabetic agents do not carry a risk of hypoglycemia when used alone?
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Thiazolidinediones (rosiglitazone and pioglitazone); DPP-4 inhibitors (sitagliptin, saxagliptin, linagliptin); GLP-1 receptor agonists (exenatide and liraglutide) and Metformin
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What tablet strengths are available for rosiglitazone (Avandia)? What should be the initial dose and how should it be titrated if needed?
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2 mg, 4 mg, 8 mg scored tablets. Initial dose: 4 mg once daily or 2 mg BID. Titrate if the response is inadequate after 3 months to 8 mg once daily or 4 mg BID.
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What tablet strengths are available for pioglitazone (Actos)? What should be the initial dose? What is the maximum dose for monotherapy and for combination therapy?
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Tablet strengths are 15 mg, 30 mg, & 45 mg. Initial dose: 15 to 30 mg once daily. Maximum dose: 45 mg daily for monotherapy, 30 mg daily for combination therapy.
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Describe lab monitoring thiazolidinediones?
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Monitor ALT at baseline and then "periodically." If ALT > 2.5 x ULN at baseline, don't start. If ALT > 3 x ULN, discontinue.
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What are the two meglitinides and by how much do they lower A1C?
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Repaglinide (Prandin) and Nateglinide (Starlix). They decrease A1c by 1 to 2%.
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Which anti-diabetic agents that stimulate insulin secretion are safe to use in patients who have a sulfa allergy? What class of agents are not safe in these patients?
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The meglitinides (repaglinide and nateglinide) are safe to use in patients who have a sulfa allergy. The sulfonylureas are not safe in these patients.
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What tablet strengths are available for repaglinide (Prandin)? How should it be dosed initially? When should it be titrated and to what maximum?
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Tablet strengths: 0.5 mg, 1 mg, & 2 mg. If A1c < 8% or no other meds, dose 0.5 mg TID. If A1c > 8% or HX of other meds, dose 1 to 2 mg TID. Titrate after one week. Maximum dose 4 mg per dose (16 mg per day).
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What tablet strengths are available for nateglinide (Starlix)? What should be the initial dosing? What is the maximum dosage?
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Tablet strengths: 60 mg & 120 mg. Initial dosing: 60 to 120 mg TID before meals. Maximum dose: 120 mg TID.
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One of the meglitinides requires caution with either renal dysfunction or hepatic dysfunction. Another does not. Which is which?
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Repaglinide (Prandin) requires caution in both renal and hepatic impairment, while no dosage adjustments are necessary for nateglinide (Starlix) in either case.
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What five criteria are met by patients expected to respond to sulfonylurea therapy?
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1) Recent diagnosis (w/i 5 yrs), 2) 110 to 160% IBW, 3) fasting glucose < 200 mg/dL, 4) insulin < 40 units / day, & 5) > 40 yrs old
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By what amount do sulfonylureas decrease A1c?
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1.0 to 2.0%
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What are five contraindications to sulfonylureas?
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1) T1DM, 2) Pregnancy or Lactation, 3) Hypersensitivity (sulfa allergy), 4) Severe renal or hepatic dysfunction, & 5) Acute stressors
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What tablet strengths are available for glyburide? How is it dosed and what is the max and max effective dose?
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Tablet strengths: 1.25 mg, 2.5 mg, 5 mg. Dose once daily to 10 mg, then BID (titrate typically by doubling the dose). The max dose is 20 mg/day (max effective dose: 10 mg/day)
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What tablet strengths are available for micronized glyburide? How is it dosed and titrated?
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Tablet strengths: 1.5 mg, 3 mg, 6 mg. Initiate once daily, up to 6 mg/day, then BID.
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What are the brands of glyburide?
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DiaBeta & Micronase
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What is a brand of glipizide?
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Glucotrol
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What tablet strengths are available for glipizide? How is it initiated and titrated and what is the max and effective max dose?
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Tablet strengths: 5 mg & 10 mg. Initiate once daily to 10 mg, then BID (for regular release). The max dose is 40 mg/day (effective max 20 mg/day).
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What is a brand of glimepiride?
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Amaryl
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List three 2nd generation sulfonylureas.
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Glyburide, Glipizide, & Glimepiride
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What tablet strengths are available for glimepiride? How is it dosed and what is the maximum daily dosage?
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Tablet strengths: 1 mg, 2 mg, & 4 mg. Dosing: 1 to 2 mg once daily w/ meal. Max: 8 mg/day.
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Which 2nd generation sulfonylurea has active metabolites and thus requires dosage adjustments for kidney failure? How is it initially dosed in cases of kidney failure or hepatic dysfunction?
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Glimepiride: start w/ 1 mg daily.
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How often are dosage adjustments made when titrating sulfonylureas in non-elderly patients? How often in elderly patients?
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Non-Elderly: 1 to 2 wks, Elderly: 3 to 4 wks.
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Is metformin useful in the treatment of type 1 diabetes patients? What about pediatric patients who have type 2 diabetes?
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Yes. And yes.
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If a patient on combination therapy with metformin and a sulfonylurea experiences hypoglycemia, which of the two should be adjusted?
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The sulfonylurea should be adjusted, not metformin.
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By how much will metformin typically lower A1c?
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1.0 to 2.0%
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List four non-diabetes benefits of metformin.
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1) Decreased cancer risk, 2) Decreased breast cancer incidence, 3) Decreased colorectal cancer risk, & 4) Potential neuron growth & improved memory (observed in mice).
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What are six symptoms of lactic acidosis?
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Rapid onset of the following: 1) Feeling weak, tired, or uncomfortable, 2) Unusual muscle pain, 3) Trouble breathing, 4) Feeling cold, dizzy, or lightheaded, 5) Sudden onset of a slow or irregular heartbeat, & 6) "Flu-like" symptoms
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How commonly do patients taking metformin develop lactic acidosis and how serious is it?
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Rare (less than 1 in 1,000 patients), but severe (50% fatality).
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What are 7 contraindications for metformin due to heightened risk of lactic acidosis?
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1) Kidney impairment (SCr > 1.5 mg/dL in men or > 1.4 mg/dL in women), 2) Hepatic disease & alcohol abuse, 3) Respiratory insufficiency (e.g. COPD), 4) Hypoxemic condition, 5) Cardiovascular collapse, 6) Acute MI, & 7) Septicemia
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How should metformin be titrated? What is the minimum effective dose? What is the maximum allowable dose?
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Titrate: Weekly to biweekly (monthly in elderly) in 500 mg increments. Minimum effective dose: 1,500 mg per day. Max dose: 2,000 vs. 2550 mg per day.
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By how much does acarbose (Precose) lower postprandial glucose alone (w/ sulfonylurea)? By how much does it decrease A1c?
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Lowers postprandial glucose 50 to 60 mg/dL alone (85 mg/dL w/ sulfonylurea). Decreases A1c by 0.7 to 1.0%.
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What tablet strengths are available for acarbose? How is it initiated and titrated?
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Tablet strengths: 25 mg, 50 mg, & 100 mg. Initiate 25 mg once or twice daily, increasing to TID. Titrate in 25 mg increments every 4 to 8 weeks.
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What is the maximum dosage of acarbose?
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50 mg TID for patients < 60 kg, 100 mg TID for patients > 60 kg.
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By how much does sitagliptin lower A1c?
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0.5%
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What is the usual dosing with sitagliptin?
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100 mg once daily
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What is the dosing of sitagliptin when CrCL is 30 to 50 mL/min?
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50 mg once daily
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What is the dosing of sitagliptin when CrCL is < 25 mL/min?
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25 mg once daily
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What tablet strengths are available for saxagliptin (Onglyza)? How is it dosed?
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Tablet strengths: 2.5 mg & 5 mg. Dosing: 2.5 to 5 mg daily (only 2.5 mg daily if CrCL < 50).
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By how much does saxagliptin lower A1c?
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0.5%
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What tablet strengths are available for sitagliptin (Januvia)?
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Tablet strengths: 25 mg, 50 mg, & 100 mg
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Which of the DPP-4 inhibitors has been reported to cause serious allergic reactions in rare cases?
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Sitagliptin
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By how much does linigliptin lower A1c?
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0.5%
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What tablet strengths are available for linagliptin (Tradjenta)? How is it dosed?
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Tablet strengths: 5 mg. Taken once daily.
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Which of the three DPP-4 inhibitors on the market does not need to be adjusted for renal impairment?
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Linagliptin (Tradjenta)
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What is the brand name for Exenatide?
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Byetta
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What is the mechanism of action for exenatide?
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It mimics action of a gut hormone called GLP-1 that spurs insulin production in response to elevated postprandial glucose, suppresses postprandial glucagon levels, and slows gastric emptying.
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By how much does exenatide decrease A1c?
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~1%
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What is the primary side effect of exenatide?
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Nausea
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With what patient populations would exenatide be a particularly bad idea?
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Patients having either severe GERD or gastroparesis (due to the main ADR (nausea)).
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Describe dosing, administration, and titration for exenatide.
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Start: 5 mcg BID (may titrate after 1 month to a max of 10 mcg BID). Inject 1 hour prior to AM and evening meals.
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What is unique about the GLP-1 receptor agonists (exenatide & liraglutide) as a class of anti-diabetic agents regarding a beneficial side effect.
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Exenatide causes weight loss.
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How might the dosage of a sulfonylurea need to be adjusted when initiating exenatide and why?
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The dose of sulfonylurea may need to be reduced by 25 to 50%. Exenatide slows gastric emptying, so the insulin levels may end up too high if the sulfonylurea dose isn't reduced.
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Which of the GLP-1 receptor agonists has to be adjusted for renal impairment?
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Exenatide. Avoid if CrCL < 30 mL/min and also in ESRD (end stage renal disease). Exercise caution with starting or increasing dose if CrCL is 30 to 50 mL/min.
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What is the brand name of the once weekly formulation of exenatide?
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Bydureon
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What is the brand name of Liraglutide?
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Victoza
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What is the mechanism of action for liraglutide?
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It mimics action of a gut hormone called GLP-1 that spurs insulin production in response to elevated postprandial glucose, suppresses postprandial glucagon levels, and slows gastric emptying.
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By how much does liraglutide lower A1c?
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1.3 to 1.6%
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Describe initial dosing, titration, and max dose for liraglutide.
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Initial dosing of 0.6 mg once daily x 1 week (does not matter when w/ respect to meals). Increase to 1.2 mg once daily. Max dose 1.8 mg daily.
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How might the dosage of an insulin secretagogue or sulfonylurea need to be adjusted when initiating liraglutide and why?
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The recommended dose reduction of an insulin secretagogue or sulfonylurea is 50% and sometimes it can be stopped completely. Liraglutide slows gastric emptying, so the insulin levels may end up too high if the sulfonylurea dose isn't reduced.
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Which GLP-1 receptor agonist does not require dosage adjustments for either renal or hepatic impairment?
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Liraglutide
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What is the minimally effective dose of liraglutide?
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1.2 mg once daily
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What are the most common ADRs of liraglutide?
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N/V/D, dyspepsia
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Which anti-diabetic medication carries a black box warning for thyroid C-cell tumors, including medullary thyroid carcinoma, in rats?
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Liraglutide
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Describe the REMS program for liraglutide.
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A letter is sent to physicians once a year to warn of a potential risk of acute pancreatitis and of thyroid C-cell tumors with liraglutide.
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How do exenatide and liraglutide compare w/ respect to efficacy at lowering A1c and facilitating reductions in body weight?
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Liraglutide is superior at lowering A1c. The two are similar in facilitating reductions in body weight.
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What are the effects of amylin and by what cell type is it produced?
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Amylin is produced by pancreatic beta-cells. It slows the rate of gastric emptying, decreases postprandial glucagon concentrations, and is said to have a centrally mediated effect on appetite.
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What is the brand name of Pramlintide?
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Symlin
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What is the mechanism of action for Pramlintide?
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Pramlintide is a synthetic analog of human amylin. It slows gastric emptying, decreases postprandial glucagon concentrations, and is suggested to have a centrally-mediated effect on appetite.
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What is very important to do when initiating pramlintide?
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Reduce the preprandial rapid- or short-acting insulin dose by 50% (even in patients on a 70/30 mix).
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What it the duration of action of pramlintide and by how much does it lower A1c?
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Duration of action: 3 hrs. A1c reduction: 0 to 0.5%.
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What are the selling points, so to speak, with respect to the therapeutic effects of pramlintide?
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It significantly reduces postprandial glucose levels and results in more consistent blood glucose levels throughout the day, leading to an improvement in the number of blood glucose levels within the normal glycemic range of 70 to 180 mg/dL.
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Describe the initiation, titration, and max of pramlintide dosing in patients having type 1 diabetes mellitus.
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Start 15 mcg prior to major meals (perhaps the major meal only at first). Titrate in 15 mcg increments when no nausea has been present for 3 days. Max: 60 mcg per dose.
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Describe the initiation and titration of pramlintide dosing in patients having type 2 diabetes mellitus.
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Start 60 mcg prior to major meals. Increase to 120 mcg when no nausea has been present for 3 to 7 days.
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Which 5 categories of type 2 diabetes mellitus patients typically need insulin?
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1) Stress to the body (major illness or injury), 2) Hypersensitivity/intolerance to oral agents, 3) Primary or secondary failure with oral agents, 4) Initial treatment for patients with ketosis, severe glycosuria, or weight loss, & 5) Lean type 2 patients.
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What should be done with oral agent therapy upon initiating insulin therapy?
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If the therapy is just basal insulin, oral agents are typically continued. If the therapy is prandial insulin, sulfonylureas or glinides are typically discontinued, while metformin is continued.
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Should the insulin secretagogue be abruptly discontinued or tapered when initiating prandial insulin therapy?
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Taper by cutting the dose by 50%, while titrating the insulin dose. Repeat, and then d/c the insulin secretagogue with the third insulin dose adjustment.
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Describe typical insulin dosing in type 2 diabetes mellitus.
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0.1 to 0.2 units/kg for single basal daily dosing initially and 0.2 to 0.5 units/kg/day total with the addition of prandial dosing.
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